MEDICARE: NORTHWEST OPTOMETRIC ASSOCIATES, LTD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	046008854	IL

General Provider Information

NPI Number	:	1609908920
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST OPTOMETRIC ASSOCIATES, LTD

Provider Business Mailing Address
First Line	:	4970 N HARLEM AVE
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-3552
Country	:	US
Telephone Number	:	708-867-7838
Fax Number	:	708-867-5869

Provider Business Practice Location Address
First Line	:	4970 N HARLEM AVE
Second Line	:
City	:	HARWOOD HEIGHTS
State	:	IL
Zip	:	60706-3552
Country	:	US
Telephone Number	:	708-867-7838
Fax Number	:	708-867-5869

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DENICE ANN RICE-KELLY
Credential	:	O.D.
Telephone Number	:	708-867-7838

Provider Enumeration Date	:	03/12/2007
Last Update Date	:	01/04/2008

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